2500-FM-BWM0508a
6/2005
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WASTE MANAGEMENT
APPLICATION FOR REGISTRATION
WASTE TIRE COLLECTION PROGRAM
1. Applicant/Sponsor:
Address:
Lead contact person:
Phone number:
2. Date(s) of event:
Title:
(
)
From:
3. Applicant/Sponsor is:
To:
Local municipality
County
Non-profit Organization
Lead municipality or county for multi-municipality or multi-county sponsored
program. List other sponsors below:
4. Contractor Information
Name of Collection Contractor:
Permit #:
Permit Expiration Date:
Lead Contact Person:
Title:
Address:
Phone #:
City:
State:
(
)
Zip:
Name of Hauler:
Authorization #:
Authorization Expiration Date:
Lead Contact Person:
Title:
Address:
City:
Phone #:
State:
(
)
(
)
Zip:
Name of location/business receiving waste tires:
Lead Contact Person:
Title:
Address:
City:
Phone #:
State:
Zip:
Please provide a permit # or attach other documentation establishing the receiver of the waste tires to be lawfully
allowed to manage the waste tires at the receiving facility.
Permit #:
Brief description of how tires will be recycled, recovered or reused.
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2500-FM-BWM0508a
5.
6/2005
Collection Site Information
Location #1:
Date(s) of event:
From:
To:
Cosponsor:
Estimated number of participants:
Contractor:
Transporter:
Location #2:
Date(s) of event:
From:
To:
Cosponsor:
Estimated number of participants:
Contractor:
Transporter:
Location #3:
Date(s) of event:
From:
To:
Cosponsor:
Estimated number of participants:
Contractor:
Transporter:
Location #4:
Date(s) of event:
6.
From:
To:
Cosponsor:
Estimated number of participants:
Contractor:
Transporter:
Waste Estimates – For each type of waste that is expected to be collected at each location, please enter the
following:
Number of
Participants
Location
Number of tires
collected
Pounds of tires
collected
#1
#2
#3
#4
Conversions – Assume 1 tire equals 20 pounds
7.
Site Description and Management Plan
a.
Attach an 8 ½ by 11 inch plan for each of the collection sites showing the design of the collection area and
how traffic will flow through the collection site. Include a discussion of people and traffic control. This
statement should include entrance/exit information, identification of collection personnel, and how unloading of
tires from vehicles will be handled. If submitting the application by email, please attach the diagram in a .pdf
or .jpeg format.
b.
If the site is not owned by the sponsor, a “Site Use Authorization Statement” signed by the owner of the site
indicating the owner has given the sponsor permission to use the location to conduct the event must be
attached.
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2500-FM-BWM0508a
8.
6/2005
Site Safety and Insurance
Please provide the following information:
a.
Evidence of a minimum of $2.0 million general insurance liability coverage by the collection contractor or tire
collection site operator. If submitting the application by email, please attach this in a .pdf or .jpeg format.
b.
Emergency phone numbers:
1. Fire
2. Police
3. Ambulance
9.
c.
A traffic control plan in the event of a traffic back-up at the collection site. If submitting the application by
email, please attach this in a .pdf or .jpeg format.
d.
An explanation of the provisions to shut down the collection in the event of an emergency.
e.
Please describe the security arrangements to prevent fires or illegal dumping of tires at the collection site and
also security provisions for tires left at the collection site overnight. All tires must be removed from the
collection site within 48 hours of the collection unless otherwise approved by the Department in advance of the
collection.
Attach a Negotiated Contract
Attach copies of all negotiated contracts with collection contractors, transporters and others for which
reimbursement from DEP will be sought. The contracts do not need to be signed at the time of this application.
However, signed contracts need to be submitted to the Department prior to the collection. An application without
signed contracts is not considered complete and cannot be approved. If submitting the application by email,
please attach this in a .pdf or .jpeg format.
10.
Grant Limit
Use the formula below to determine the maximum amount of money the Department will reimburse the sponsor,
provided the application is approved by the Department.
2000 census
Population
X
Multiplication
Factor
X
Amount
Per tire
=
X
.04
X
$2.00
=
Total $
If the above amount under “Total $” is greater than $25,000, enter $25,000 next to “Maximum Amount of Grant.”
Otherwise, please enter the amount above.
Maximum Amount of Grant
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$
2500-FM-BWM0508a
10.
6/2005
Grant Limit (continued)
If your collection event is approved by the Department, the maximum amount of grant money awarded will be
confirmed in the Department’s approval letter.
If the actual cost of the collection exceeds the maximum amount of grant money approved by the Department, the
sponsor may request additional grant funding through the Department’s household hazardous waste program,
subject to the limitations established under Act 190 and the household hazardous waste program. Additional
funding through the household hazardous waste program must be requested utilizing the grant request form
associated with that program.
All grant requests under the Waste Tire Collection Program must be submitted to the Department by
July 15, 2003.
11.
Certification
This is to certify that I have personally examined and am familiar with the information in this application and
attached documents. I have reviewed the legislation and regulations that pertain to waste tire collection programs
and I am aware of the Department of Environmental Protection’s requirements for this application. By submitting
this application by email or by signing below, I acknowledge that, to the best of my knowledge, the submitted
information is true, accurate, and complete. I am aware that there are significant penalties for submitting false
information.
Signature of Sponsor’s Authorized Official
Date
Email address
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